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Contributor's Note

Palliative Medicine has been a part of me from the beginning of my career. As an Internal Medicine resident in the early 1980s, I saw many patients suffering while receiving futile care. I recall that as an ICU resident, rounding on the weekend with an attending of similar mind, taking more than half the patients off ventilators because there was no hope of recovery yet no one told them. As physicians, we tend to always look at disease as an enemy to be vanquished. However, disease is a part of life, and there are times we need to surrender to the inevitable and leave this place with grace and dignity. The Hippocratic Oath states: “I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.” It is easy to get burnt out, to get cynical and jaded, but we need to remember why we became physicians, what we said in that interview when we applied to medical school. It is a privilege for us to take care of patients. We must always keep them informed and respect their wishes. To me, there is no comparison to dying in the ICU or at home and if that is the patient’s last hope, I would do everything it takes to make sure it happens.

To Die At Home

She was an elderly lady who came to the ED septic. I was on call for palliative care the 22nd day of her hospitalization. The intensivist said she has become ventilator dependent. One of her sons visited every day – we arranged a meeting to coincide with his presence.

She was alert and understood her predicament. We talked as best we could, her writing things, the son filling in info, answering yes and no questions. Her husband of 57 years had died about 10 years ago. She lived in her own house, but it was divided up so her other son could live there. He paid rent enabling her to keep her home. She had no desire to live on a ventilator. She had a full and meaningful life. Her son agreed and was willing to honor her wishes for terminal extubation. However, she had one wish – to die at home. Usually patients who want their ventilator turned off do so in the hospital. However, I felt I needed to make that wish come true. The intensivist did not think she would make it home if we extubated her in the ICU. There was only one solution – send her home on the ventilator and remove her ET tube there. I had never done that before but I couldn’t see why not. The hospice manager listed many objections and concerns. I worked with my colleague, a skilled palliative care nurse specialist (CNS), as well as the nurse manager of the ICU, and we dealt with each objection.

Three days later we were ready. The patient was picked up by critical care transport (CCT) at 9 am while I waited at her house. She arrived, on a portable ventilator, but her medicine had not arrived. There were issues with pharmacy about dispensing IV morphine (MS) that we had already addressed, but apparently our arrangements fell through. I quickly called my team, and the ICU manager showed up with the MS 30 minutes later. While we waited, we got her settled in her bed. The CCT RN stayed and helped. We put her favorite movie on her TV. Her son held her hand. The hospice nurse arrived and started doing her evaluation. I looked around her home. Why was it important for her to be there? It was obvious. Her home was filled with love and memories. All her shelves were filled with knick-knacks. She had very old appliances, all well maintained. You could tell that everything had some meaning. When her medicine arrived, I removed her tube and gave her IV medication. We made her comfortable. She was awake and could talk to little. She enjoyed her movie. I stayed for a couple of hours to make sure she was stable. While I sat and waited, I was looking around and observing everything I saw. One item was a Salvatore Dali style melting clock. I never learned what that meant to her.

She died later that night, comfortable, at home with her family. The next day I went onto Amazon and bought the same clock. It sits over my desk and every day I look at it and think of her.